Form Gsa 3695 - Mentor-Protege Program Application - 2009
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5OMB Number: 3090-0286
MENTOR-PROTÉGÉ PROGRAM APPLICATION
Expires: 7/31/2012
A signed mentor-protégé Application, including the Agreement for each mentor-protégé relationship must be
submitted with this application to the Office of Small Business Utilization (OSBU) for approval. Additional
information may be provided in narrative form. Submit your application via e-mail to mentorprotege@gsa.gov
1. Mentor Firm Information.
Provide the following:
(See 519.7010(a))
NAME OF FIRM
CONTACT NAME
POSITION TITLE
ADDRESS
TELEPHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
HOMEPAGE
2. Protégé Firm Information.
Provide the following:
(See 519.7010(a))
NAME OF FIRM
CONTACT NAME
POSITION TITLE
ADDRESS
TELEPHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
HOMEPAGE
3. Current Status of Mentor.
a.
Is a small business (See 519.7006(a)).
Is not a small business (See 519.7006(a)).
Is currently performing under at least one active, approved subcontract plan
b.
(Small Business is exempt) (See 519.7009(b)(1)).
c.
Is eligible, as of the date of this application, for award of federal contracts (See 519.7006(b)).
d. Number of Proposed protégé arrangements:
(See 519.7009(b)(2))
e. Data on all current GSA contracts (See 519.7009(b)(3)) and subcontracts (See 519.7009(b)(3)) to include:
PRIME CONTRACT AWARDS
Period of Performance
Awarding GSA Office and
Contract Number and
Contract Value
(including options)
Point of Contact
Contract Type
(including options)
$
$
$
$
$
When applicable, indicate the technical program effort(s) (Program Title), name of GSA
Project Manager and/or Contracting Officer’s Representative (including contact
information)(See 519.7009(b)(3)).
GENERAL SERVICES ADMINISTRATION
GSA 3695 9/2009
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